Faculty Bibliography

Objectives: * Identify components of a new mode of palliative care delivery for the growing population of patients with advanced illness discharged from the ED. * Discuss success and challenges for the delivery of a nurse-led telephonic palliative care program. Original Research Background: The demand for palliative care has outstripped the supply of trained physicians. Nurse-led telephonic palliative care is a potential model to address the growing need for palliative care. Research Objectives:: * Describe the development of a novel nurse-led telephonic palliative care program for seriously ill patients who are discharged from the Emergency Department (ED). * Describe the program implementation. * Share preliminary operational and clinical outcomes.
Method(s): The nurse-led telephonic palliative care program is part of the EMPallA research study, a large Patient-Centered Outcomes Research Institute (PCORI)-funded randomized controlled trial comparing facilitated, outpatient specialty palliative care to nurse-led telephonic case management for seriously ill patients after an ED visit. Three palliative care certified nurses, under supervision of a Hospice and Palliative Medicine (HPM) physician, provided telephonic care to patients across seven states. Patients received weekly calls from the telephonic nurse for six months.
Result(s): Of the first 100 patients who completed the telephonic arm intervention, 78 patients (78%) were actively engaged, while 9 patients were lost to follow-up and 13 patients withdrew. Eighteen patients (18%) died during the intervention and, of those, 11 (61%) enrolled in hospice prior to death. The average caseload per nurse was 18 patients per week and an average of 10 calls were made to each patient over the six-month period. Telephonic nurses made a total of 206 outgoing calls or emails to the patient's care teams and received an average of 222 responses.
Conclusion(s): Preliminary results show that seriously ill patients and their caregivers are willing to engage with telephonic nurses. A majority of patients remained engaged throughout the six-month intervention, and nearly two-thirds of patients who died utilized hospice prior to death. Implications for Research, Policy or Practice: This model has the potential to augment traditional physician-led outpatient palliative care and may be preferable for many patients who have difficulty traveling to a clinic setting for palliative care.
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Objectives/UNASSIGNED:Since the number of individuals who use substances in the United States has markedly increased every year, substance use is a significant public health concern. The current study examines the possible risk and protective factors associated with triple comorbid trajectories of longitudinal alcohol, tobacco, and cannabis use from age 14 to 36. Methods/UNASSIGNED:A community sample of 674 participants (53% African Americans and 47% Puerto Ricans; 60% females) were recruited from the Harlem Longitudinal Development Study. Multinomial logistic regression analyses were conducted to examine the associations between the risk (low self-control, peer drug use) and protective (parent-child attachment, family church attendance) factors at age 14 and membership in the triple trajectory groups derived from a multivariate growth mixture model. Results/UNASSIGNED:Low self-control and peer drug use were associated with an increased likelihood of being a member in the triple comorbid trajectory groups compared to the reference group (i.e., low alcohol, no tobacco, and no cannabis use). On the other hand, parent-child attachment and family church attendance were associated with a decreased likelihood of being a member in the triple comorbid trajectory groups compared to the reference group. Conclusions/UNASSIGNED:Treatment programs for adolescents who use substances may be more helpful if their parents and/or friends could also participate together with the adolescent, rather than only the adolescent participates in the treatment programs. Further research is needed to gain a greater understanding of the conceptual nature of the relationship between earlier risk and protective factors and later substance use patterns.

BACKGROUND:Research on frequent emergency department (ED) use shows that a subgroup of patients visits multiple EDs. This study characterizes these individuals. OBJECTIVE:The objective of this study was to determine how many frequent ED users seek care at multiple EDs and to identify sociodemographic, clinical, and contextual factors associated with such behavior. RESEARCH DESIGN/METHODS:We used the 2011-2014 Healthcare Cost and Utilization Project State Emergency Department Databases data on all outpatient ED visits in New York, Massachusetts, and Florida. We studied all adult ED users with ≥5 visits in a year and defined multisite use as visits to ≥3 different sites. We estimated predictors of multisite use with multivariate logistic regressions. RESULTS:Across all 3 states, 1,033,626 frequent users accounted for 7,613,077 ED visits. Of frequent users, 25% were multisite users, accounting for 30% of the visits studied. Frequent users with at least 1 visit for mental health or substance use-related diagnosis were more likely to use multiple sites. Uninsured frequent users and those with public insurance were associated with less use of multiple EDs than those with private coverage while lacking consistent coverage by the same insurance within each year were associated with using multiple sites. CONCLUSIONS:Health policy interventions to reduce duplicative or unnecessary ED use should apply a population health perspective and engage multiple hospitals. Community-level preventive approaches and a stronger infrastructure for mental health and substance use are essential to mitigate multisite ED use.

BACKGROUND:Although home telemonitoring (TM) is a promising approach for patients managing their chronic disease, rehabilitation using home TM has not been tested for use with individuals living with chronic obstructive pulmonary disease (COPD) residing in underserved communities. OBJECTIVE:This study aimed to analyze qualitative data from focus groups with key stakeholders to ensure the acceptability and usability of the TM COPD intervention. METHODS:We utilized a community-based participatory research (CBPR) approach to adapt a home TM COPD intervention to facilitate acceptability and feasibility in low-income African American and Hispanic patients. The study engaged community stakeholders in the process of modifying the intervention in the context of 2 community advisory board meetings. Discussions were audio recorded and professionally transcribed and lasted approximately 2 hours each. Structural coding was used to mark responses to topical questions in interview guides. RESULTS:We describe herein the formative process of a CBPR study aimed at optimizing telehealth utilization among African American and Latino patients with COPD from underserved communities. A total of 5 major themes emerged from qualitative analyses of community discussions: equipment changes, recruitment process, study logistics, self-efficacy, and access. The identification of themes was instrumental in understanding the concerns of patients and other stakeholders in adapting the pulmonary rehabilitation (PR) home intervention for acceptability for patients with COPD from underserved communities. CONCLUSIONS:These findings identify important adaptation recommendations from the stakeholder perspective that should be considered when implementing in-home PR via TM for underserved COPD patients. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03007485; https://clinicaltrials.gov/ct2/show/NCT03007485.

Fields as diverse as human genetics and sociology are increasingly using polygenic scores based on genome-wide association studies (GWAS) for phenotypic prediction. However, recent work has shown that polygenic scores have limited portability across groups of different genetic ancestries, restricting the contexts in which they can be used reliably and potentially creating serious inequities in future clinical applications. Using the UK Biobank data, we demonstrate that even within a single ancestry group (i.e., when there are negligible differences in linkage disequilibrium or in causal alleles frequencies), the prediction accuracy of polygenic scores can depend on characteristics such as the socio-economic status, age or sex of the individuals in which the GWAS and the prediction were conducted, as well as on the GWAS design. Our findings highlight both the complexities of interpreting polygenic scores and underappreciated obstacles to their broad use.

Background/UNASSIGNED:Cigarette smoking is the most common form of tobacco consumption but other methods have grown in popularity. In the United Arab Emirates and other Gulf countries, smoking dokha, a form of tobacco mixed with herbs and spices in a midwakh pipe, is common. Aims/UNASSIGNED:The aim of this study was to determine the prevalence of midwakh use in school students in Lebanon and factors associated with its use. Methods/UNASSIGNED:Data on tobacco use from the Lebanon Global School-based Student Health Survey (GSHS), 2017 were analysed, including current midwakh use (defined as midwakh use at least once in the 30 days before the survey). The survey includes school students in grades 7-12 (12-18 years). Current midwakh use was analysed according to sociodemographic and tobacco-related variables using bivariate and logistic regression analyses. Results/UNASSIGNED:Of the 5590 students included in the analysis, 4.6% were current midwakh users. Current midwakh use was significantly more prevalent in students 13 years and older and in male students (P < 0.01). Current use was also statistically significantly more prevalent in students in public than private schools. Current cigarette smoking (OR = 15.22; 95% CI: 11.08-20.90), ever use of a waterpipe (OR = 9.61; 95% CI: 6.66-13.86) and parental smoking (OR = 1.56; 95% CI: 1.05-2.31) were also significantly associated with current midwakh use. Conclusion/UNASSIGNED:Although midwakh use is low in Lebanon, the patterns of association of midwakh use are similar to those of cigarette and waterpipe smoking in young people. Further research is needed to understand the context of midwakh use and prevent it from spreading.

BACKGROUND:The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. METHODS:A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. RESULTS:The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. CONCLUSIONS:CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.

IMPORTANCE/OBJECTIVE:In the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline, the definition of hypertension was lowered from a blood pressure (BP) of greater than or equal to 140/90 to greater than or equal to 130/80 mm Hg. The new diastolic BP threshold of 80 mm Hg was recommended based on expert opinion and changes the definition of isolated diastolic hypertension (IDH). OBJECTIVE:To compare the prevalence of IDH in the United States, by 2017 ACC/AHA and 2003 Joint National Committee (JNC7) definitions, and to characterize cross-sectional and longitudinal associations of IDH with outcomes. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Cross-sectional analyses of the National Health and Nutrition Examination Survey (NHANES 2013-2016) and longitudinal analyses of the Atherosclerosis Risk in Communities (ARIC) Study (baseline 1990-1992, with follow-up through December 31, 2017). Longitudinal results were validated in 2 external cohorts: (1) the NHANES III (1988-1994) and NHANES 1999-2014 and (2) the Give Us a Clue to Cancer and Heart Disease (CLUE) II cohort (baseline 1989). EXPOSURES/METHODS:IDH, by 2017 ACC/AHA (systolic BP <130 mm Hg, diastolic BP ≥80 mm Hg) and by JNC7 (systolic BP <140 mm Hg, diastolic BP ≥90 mm Hg) definitions. MAIN OUTCOMES AND MEASURES/METHODS:Weighted estimates for prevalence of IDH in US adults and prevalence of US adults recommended BP pharmacotherapy by the 2017 ACC/AHA guideline based solely on the presence of IDH. Risk of incident atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) in the ARIC Study. RESULTS:The study population included 9590 adults from the NHANES (mean [SD] baseline age, 49.6 [17.6] years; 5016 women [52.3%]) and 8703 adults from the ARIC Study (mean [SD] baseline age, 56.0 [5.6] years; 4977 women [57.2%]). The estimated prevalence of IDH in the NHANES was 6.5% by the 2017 ACC/AHA definition and 1.3% by the JNC7 definition (absolute difference, 5.2% [95% CI, 4.7%-5.7%]). Among those newly classified as having IDH, an estimated 0.6% (95% CI, 0.5%-0.6%) also met the guideline threshold for antihypertensive therapy. Compared with normotensive ARIC participants, IDH by the 2017 ACC/AHA definition was not significantly associated with incident ASCVD (n = 1386 events; median follow-up, 25.2 years; hazard ratio [HR], 1.06 [95% CI, 0.89-1.26]), HF (n = 1396 events; HR, 0.91 [95% CI, 0.76-1.09]), or CKD (n = 2433 events; HR, 0.98 [95% CI, 0.65-1.11]). Results were also null for cardiovascular mortality in the 2 external cohorts (eg, HRs of IDH by the 2017 ACC/AHA definition were 1.17 [95% CI, 0.87-1.56] in the NHANES [n = 1012 events] and 1.02 [95% CI, 0.92-1.14] in CLUE II [n = 1497 events]). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:In this analysis of US adults, the estimated prevalence of IDH was more common when defined by the 2017 ACC/AHA BP guideline compared with the JNC7 guideline. However, IDH was not significantly associated with increased risk for cardiovascular outcomes.

BACKGROUND:Hepatitis C virus (HCV) infection is the most prevalent blood-borne infection and causes more deaths than any other infectious disease in the US. Incident HCV infection in the US increased nearly 300 % between 2010 and 2015, Community viral load (CVL) measures have been developed for HIV to measure both transmission risk and treatment engagement in programs or areas. OBJECTIVE:This paper presents a systematic review exploring the published literature on CVL constructs applied to HCV epidemiology and proposes novel CVL measures for HCV. STUDY DESIGN AND SETTING/METHODS:A systematic review was conducted of electronic databases; the search sought to identify published literature on HCV which discussed or applied CVL measures to HCV epidemiology. Novel CVL measures were constructed to apply to HCV. RESULTS:No reports examining quantitative measures of HCV CVL were identified. Using the HIV CVL literature and the specific characteristics of HCV epidemiology, five HCV CVL measures are proposed. Narrower measures focusing on those engaged-in-care may be useful for program evaluation and broader measures including undiagnosed people may be useful for surveillance of HCV transmission potential. CONCLUSION/CONCLUSIONS:Despite their potential value, CVL constructs have not yet formally been developed and applied to HCV epidemiology. The CVL measures proposed here could serve as valuable HCV program and surveillance measures. There is a need for informative surveillance measures to enhance policy and public health responses to achieve HCV control. Further study of these proposed HCV CVL measures to HCV epidemiology is warranted.